Individual at Mandeville House

Investigation into the circumstances surrounding the
death of a man at an Approved Premises in the South
Wales Probation Area in September 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2009
This is the report of an investigation into the circumstances surrounding the
death of a resident at an approved premises in the South Wales Probation
Area. The man died in his room on 12 September 2008. The cause of his
death was recorded as cardiomegaly (enlargement of the heart due to heart
failure). I offer my sincere sympathy and condolences to the man’s family for
their loss, as I do to all of those who have been affected by his passing.
The investigation was carried out on my behalf by my colleague. I would like
to thank the deputy manager of the approved premises for his assistance in
liaising with my investigator. I would also like to thank all of his colleagues for
their full and ready co-operation with the investigation.
The man died suddenly and unexpectedly. My report makes two
recommendations – one of which is that all staff at the approved premises are
trained in basic first aid in line with national guidelines.
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2009
2
CONTENTS
Summary 4
The investigation process 5
The approved premises 7
Key findings 8
Issues 12
Recommendations 18
3
SUMMARY
The man arrived at the approved premises on 20 June 2008, following his
release from prison that day. This was the first time that he had lived in an
approved premises. The man’s stay at the hostel began three weeks earlier
than was initially expected. This was because the Parole Board had
instructed that the man be released from prison early, as his recall to custody
following an earlier release on licence in March 2008 was technically unlawful.
The man found it difficult to settle at the approved premises, and initially
refused to co-operate with key work sessions (one to one meetings with a
designated member of staff to discuss any issues in depth). However, he
established some rapport with his key worker and began to settle into hostel
life, spending a lot of time working in the garden. He still had some bad days
though and did not get on with every member of staff. The man also raised
concerns about the standard of accommodation that had been arranged for
him to live in when he left the approved premises, and refused to accept it.
Instead, he found private accommodation himself and was able to put a
deposit down on a small house. The man was due to move in on 7 October.
A fellow resident said that he saw the man looking unwell on the night of 11
September (although examination of hostel records indicates that the resident
may have meant 10 September). Nevertheless, the man did not report any
illness to hostel staff. Indeed, he was seen regularly by staff on 11
September and no concerns were noted.
At around 8.20am on 12 September, a fellow resident went to the man’s room
to speak to him. He ran straight back down to the main office and reported
that the man had fainted. Two members of staff, including the deputy
manager, ran up to the man’s room. They found him semi-conscious and with
laboured breathing, and called an ambulance immediately.
The paramedics arrived at around 8.30am, shortly after the man’s condition
had deteriorated. They attempted to resuscitate him but were unsuccessful.
The man’s death was pronounced at 9.00am.
My investigation found that not all staff at the approved premises are trained
in basic first aid, which is not in line with instructions provided in Probation
Circular 35/2006. I have recommended that the Chief Officer addresses this
and considers the benefits of training all staff in cardio-pulmonary
resuscitation. I make a further recommendation regarding the support
available to staff who are affected by the death of a resident.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 15 September 2008, when my
investigator issued notices announcing the investigation to staff and
residents. The notices included an invitation to those who wished to
submit information relating to the man’s death to make themselves known.
One resident came forward as a result.
2. My investigator visited the approved premises on 18 September. During
his visit he was shown around the hostel, including the room where the
man lived. He was also given copies of all documentation relating to the
man. My investigator returned on 1 October when he interviewed three
members of staff and two residents, including the one who had responded
to the notices.
3. One of my family liaison officers contacted the man’s second wife and his
brother to inform them of the investigation. My investigator and my family
liaison officer subsequently visited the man’s brother on 23 October. At
the meeting, the man’ brother raised the following issues that he wished
the investigation to address:
 The man had told him that he could not get his medication when he
was in prison.
 The man was concerned that all prescribed medication was held in the
office at the approved premises, which meant that residents could not
obtain their medication quickly.
 The man had difficulty finding accommodation to live in when he left
the approved premises, and was offered a bedsit that was unsuitable.
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THE APPROVED PREMISES
4. The purpose of an approved premises is to provide an advanced level of
residential supervision in the community, alongside a supportive and
structured environment. Whilst residents have to comply with their
individual licence or bail conditions, curfews, and the hostel’s house rules,
they are essentially free to come and go from the building. All residents at
this approved premises are subject to a curfew at night.
5. The approved premises at which the man died is one of 101 approved
premises in England and Wales. It accommodates up to 26 residents in a
mixture of single and shared rooms. The hostel is staffed 24 hours a day
by probation employees, whose role is to provide support and to ensure
that the rules and licence or bail conditions are complied with. Following a
recent restructuring, the two hostels in the South Wales area share a
manager who divides her time between the premises. Each hostel has a
deputy manager who is based there permanently.
6. All residents are allocated a key worker. Regular key work sessions take
place, giving the resident the opportunity to raise and discuss any issues
or difficulties in depth. Some residents will also attend offender
management meetings or appointments with external staff in the probation
area.
7. Residents are required to register with a doctor at a local surgery during
their stay. All prescription medication is collected by hostel staff and
logged and stored at the front office. Residents collect their medication
from the office during the day and must sign to confirm the type and
quantity on each occasion. A pilot scheme was recently run in which
residents of selected approved premises held their own prescription
medication in possession. This pilot was a success and the scheme is
due to be rolled out nationally.
8. Each resident is responsible for their own health. If they require a
consultation with a doctor or visit to hospital then, unless it is an
emergency, the onus is on the resident to arrange the appointment and
transport. There are identified staff who are trained in first aid and cardio-
pulmonary resuscitation (CPR).
9. This is the first death to have occurred at the approved premises since
April 2004, when I began investigating all deaths in approved premises in
England and Wales. There have been no deaths at the other approved
premises in the South Wales Probation Area.
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KEY FINDINGS
10. The man was initially scheduled for release on 11 July, and plans were
made for him to take a place at the approved premises. However, the
Parole Board ordered his release on licence on 20 June after discovering
that his recall to custody in March 2008 was unlawful. This was because
the man’s first offence for which he was convicted was committed before
1999 and the recall should therefore have been conducted through the
Courts. As a result, the man moved into the approved premises on 20
June. During his time at the hostel the man did a lot of work in the
garden, which he apparently enjoyed.
11. The conditions of the man’s licence included an initial curfew of 8.00pm to
10.00am and the requirement to sign in four times a day, every two hours
from 12 noon to 6.00pm. Other conditions instructed the man not to live in
a house where there were children under the age of 18 (a breach of which
had resulted in his recall on 15 March) and to engage in offence based
programmes.
12. The man arrived at the approved premises on 20 June 2008. He was
given an induction to the hostel by his key worker. The man’s key worker
explained the conditions of his licence to him, including those set out in
paragraph 11. The man told his key worker that he would not be
engaging in key work sessions as he “doesn’t want anyone to know
anything about him”. The man’s key worker informed him that he was
expected to engage and that his place at the hostel might be withdrawn if
he did not.
13. The following day, the man’s key worker completed a hostel supervision
plan for the man. She noted that he suffered from high cholesterol, high
blood pressure, arthritis and an underactive thyroid. The key worker also
noted the medication that the man was taking as levothyroxine (for an
underactive thyroid), simvastatin (to lower cholesterol) and metoprolol (for
high blood pressure). It was also noted that an area of South Wales had
responsibility for accommodating the man in future and that he had
completed the necessary housing forms.
14. Two days later, on 23 June, the man was visited at the approved premises
by his offender manager. They had a meeting together with an approved
premises officer, who was standing in for the man’s key worker whilst she
was on leave. At the start of the meeting, the man spoke of his anger
about his recall to prison. As the meeting progressed, however, he
calmed down and agreed to concentrate his thoughts on the future. The
group discussed how the man would go about registering with a doctor
and sorting out his state benefits.
15. At his next meeting with his offender manager, a week later, the man was
much calmer. He was still slightly opposed to doing one to one work with
his key worker, but said that he liked his key worker. The man’s offender
manager therefore hoped that he would be able to engage with her. It
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16. Following the man’s offender manager’s next visit, on 10 July, the man’s
signing times were relaxed to three times a day, at 1.00pm, 4.00pm and
7.00pm. His curfew remained the same. At his next key work session
with the man’s key worker, five days later, the man was noted to be
settled and relaxed at the hostel. He was also getting on well with the
other residents. These sentiments were repeated at the man’s next key
work session, on 25 July, when it was also noted that he was spending a
lot of time working in the hostel garden. The man added that he
sometimes forgot to sign in, and was reminded by his key worker to do his
best with this.
17. On 5 August, following a meeting of the Multi-Agency Public Protection
Arrangements (MAPPA, a panel led by the police, probation and prison
services, with co-operation from other agencies such as social services,
that meets to assess and manage those deemed to be a high risk to the
public), the man’s curfew was relaxed by an hour and was now 9.00pm to
10.00am. He was also now only required to sign in once a day, at
4.00pm. Two days later the man visited the local probation office, where
he was seen by an offender manager who was covering the man’s
offender manager’s leave. The man was angry about an incident in the
previous week when he had not signed in on time, apparently because he
was delayed by traffic. He complained about the bureaucracy of having to
sign in and said that he was being victimised by a particular member of
staff. A note by the man’s key worker later that day indicated that the man
had become more isolated and introverted following this incident.
18. At a key work review on 10 August, his key worker noted that the man
was still isolated and not socialising with other residents. He explained
that this was because of the argument he had had about failing to sign in
on time.
19. The following week, at a MAPPA meeting on 19 August, it was noted that
the man now presented no management problems. It was agreed to issue
him with a ‘28 days notice to quit’ the approved premises, as he was close
to finding housing in an area of South Wales. The man subsequently
visited a property on 22 August. (This was the eighth property that the
local Public Protection Unit had assessed for the man. None of the
previous seven had been deemed suitable for him.)
20. After the man had viewed the property, he told his offender manager that
he was going to refuse it. He said that it was too small, with a communal
kitchen and bathroom and shared bills. The man was warned that this
would be the only property that he was offered and that there was a
danger that he would be homeless when he left the approved premises if
he was unable to arrange something himself. Nevertheless, the man was
adamant that he did not want to take the property.
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21. On 26 August, the man’s requirement to sign in at 4.00pm was removed.
He was now free to come and go as he pleased during the day, but was
still subject to curfew at night.
22. At the beginning of September, the man was assigned a new offender
manager as the previous offender manager had taken up a new job. He
met his new offender manager at her office on 3 September. The man
said that he still had not found any accommodation and would rather go
back to prison than live in the property he had recently viewed.
23. The man met his new offender manager again six days later. He said that
he had now put down a deposit on an address, although the offender
manager expressed concern that he might not be able to afford the rent.
As the property was not available until 7 October, the deputy manager of
the approved premises agreed to extend the man’s stay until that time.
24. In the hostel logbook on 10 September it was recorded that the man went
out for a drink that night and that he had “no problems”. On 11
September, the man was signed out of the hostel on two occasions. In
the morning he went out at 10.25am and returned at 11.20am. Then, in
the afternoon, he left at 3.33pm and returned at 4.45pm. This second
occasion was just after he had collected his medication from the office at
3.30pm. Hostel staff did not know where the man went on either of these
occasions, although his brother later told my family liaison officer that the
man was in a pub with him.
25. At 5.30pm, a relief worker made an entry in the hostel logbook saying
“seen [the man] regularly through the day, seemed in a very good mood”.
A curfew check is undertaken each night at around 11.00pm. On the night
of 11 September, a tick was put next to the man’s name after the check,
indicating that he was in the hostel and had no problems.
26. The following morning, at around 8.15am, a resident who was due to
leave the hostel that day approached the deputy manager and asked if it
would be possible to get a lift to his new house. The deputy manager said
that hostel staff would not be able to help him, but suggested that the
resident might ask the man for a lift, as he owned a car. The resident
therefore went to knock on the man’s door at around 8.20am.
27. Shortly afterwards, the resident ran down to the office and said that the
man had fainted. The deputy manager and a relief worker ran up to the
man’s room and entered. They found the man sitting on the floor between
his bed and the door. The deputy manager described his condition as
follows:
“He was sitting partially upright, eyes open, mouth open and moaning
… his breathing was laboured but he was breathing.”
28. The deputy manager asked an approved premises officer to call an
ambulance, which he did immediately. Prior to the paramedics arriving,
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29. At around 8.30am the paramedics arrived. At their request, the relief
worker helped to lay the man on the floor. The paramedics then began
cardio-pulmonary resuscitation (CPR). Sadly, they were unable to revive
the man. He was pronounced dead by the paramedics at 9.00am. A post
mortem report gave the cause of death as cardiomegaly (enlargement of
the heart due to heart failure).
30. Shortly afterwards, the deputy manager gathered the other residents in
the games room to inform them of the man’s death. The news was
broken to his next of kin by South Wales Police. The man’s ex-wife and
sons visited the hostel on 15 September to see where he lived and to
collect his belongings. A card of condolence was arranged and was
handed to the man’s family by a resident with whom he had been friends.
10
ISSUES
The man’s recall to custody
31. The man was initially released on licence on 1 February 2008. He was
recalled to custody on 15 March as he had broken a condition of his
licence that stated that he was not permitted to live with children under the
age of 18. The man was due for release from prison on 11 July.
However, his release was ordered by the Parole Board on 20 June after
his recall was found to have been unlawful. This was because the earliest
offence for which the man was convicted was committed before 30
September 1998, which meant that his recall should have been processed
through the Courts. The man had been due to take a place at the
approved premises on 11 July but, following the Parole Board’s decision,
he moved there three weeks early.
32. The decision to recall is initially made by the supervising offender
manager in conjunction with their line manager. A recall report is then
completed by the offender manager and signed by their line manager and
the assistant chief officer. This is faxed to the Public Protection Casework
Section (PPCS, then the Release and Recall Section) of the Ministry of
Justice, who will make the final decision on the recall within 24 hours
(unless it is an emergency recall, in which case a decision in made within
two hours).
33. At the time of his death, the man’s offender manager had only been
responsible for his supervision for around two weeks and had not
therefore been involved in his recall to custody. She told my investigator
that it was rare for a recall to have to go through the Courts and that she
had never experienced such a case.
34. Each case in which an individual has been recalled to custody is
subsequently reviewed by the Parole Board. The aim of the review is to
determine whether the decision to recall the prisoner was justified. It was
at his Parole Board review that the mistake in his recall was determined
and the man’s release from custody was ordered.
35. Given the particular condition of his licence that the man had breached, it
would be a surprise if the Court had not agreed to his recall to custody
had the recall been processed correctly. Nevertheless, it is self-evidently
worrying that an individual can be recalled to custody unlawfully, albeit
because of a technicality. Whilst I do not make a formal recommendation,
the chief officer will wish to remind staff of the importance of ensuring that
recalls to custody are processed correctly. I have also sent a copy of my
report to PPCS for their information.
36. PPCS provided the following response to my draft report:
“Clearly it is regrettable that the recall was processed incorrectly, but it
is equally likely that the officer dealing with the recall in PPCS was
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unaware of the date of the earliest offence, and there are only a
handful of long serving offenders currently in the system to whom this
would apply. It would be worth however, in pointing this out to PPCS
staff afresh just to remind them that there may be the odd occasion
when this issue does arise, and they should be mindful of the
importance of the cut off date.”
37. The South Wales Probation Trust also provided the following response:
“Guidance will be issued to ensure that careful scrutiny is given to
conviction dates when licence revocations are being considered in
future.”
Medication
38. The man’s brother told my investigator that the man had said that he could
not always obtain his medication when he was in prison. Following his
conviction in March 2007, the man spent time in HMP Swansea, HMP
Parc and HMP Usk. Since I began investigating all deaths in custody in
England and Wales in April 2004, I have completed a number of reports at
these three establishments. In one of these investigations, following the
death of a prisoner at Parc in November 2005, I recommended that a
comprehensive review of medicines management be undertaken at the
prison. This recommendation was accepted and a review, including the
recruitment of a full time pharmacist, took place in January 2006. I have
not subsequently raised the issue of medicines management in any of my
investigations at Parc, Swansea or Usk.
39. The man had been resident at the approved premises for just under three
months at the time of his death. I have not been provided with any details
of the medication that the man apparently did not receive in prison, or an
indication of when this might have happened or at which prison or prisons.
Given the time that has elapsed since any missed medication, I do not
consider that this would have had a bearing on the man’s death and so I
have not investigated the matter further.
40. The man was also concerned that his brother could not access his
medication easily at the approved premises, as it was stored in the office.
Probation Circular 33/2004 provides the current guidance on the handling
of medication of residents of approved premises. It provides the following
instruction:
“As a general rule, residents of Approved Premises are not permitted to
keep their own prescribed medication in their rooms or on their persons
… whenever a person becomes resident of Approved Premises they
must agree to hand over their medication to a supervisory member of
staff for safe-keeping.”
41. These guidelines are in place for the protection of staff and residents.
Restricting the access of residents to prescribed medication is designed to
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42. A pilot scheme was recently run in which residents of selected approved
premises held their own prescription medication in possession. This pilot
was a success and the scheme is due to be rolled out nationally.
Housing
43. The man’s brother told my investigator that the man had struggled to find
accommodation to move into on leaving the approved premises. He said
that the man was offered a place in a bedsit, but turned it down as he did
not consider it to be suitable.
44. From his arrival at the approved premises on 20 June, the man’s future
accommodation was a regular topic of discussion. It was raised in his
hostel supervision plan on 21 June, when his key worker noted that an
area of South Wales was responsible for accommodating the man.
45. A total of eight different properties were recommended by the area’s
Housing Advice Centre. However, the first seven of these were rejected
by the local Public Protection Unit as unsuitable. There were concerns for
the man’s safety in several areas. He had previously been forced to move
house during his release on licence in February 2008, due to being the
target of anti-social behaviour.
46. There were also complications in the housing process because the man
owned a property with his ex-wife. It was not therefore initially certain that
he would qualify for a council property. Moreover, the man was unable to
move into this house due to the incidents in February. He also expressed
a desire to live away from this and a neighbouring town, which narrowed
his options further.
47. A property was eventually found that was deemed to be suitable by all
parties. However, the man inspected it on 22 August but was
unimpressed and turned it down. He said that the property was too small,
with a communal kitchen and bathroom and shared bills. Despite being
warned that this was the only property that would be offered to him, the
man said that he would rather return to prison than live there.
48. The man’s offender manager described the process of finding
accommodation as a “struggle”. There were a number of barriers in place
and it took around two months for a property to be found. It is unfortunate
that the man did not consider this accommodation to be suitable.
However, he was able to find a property himself and put a deposit down
on it prior to his death.
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Issues raised by a fellow resident
49. A fellow resident of the approved premises said that he saw the man on a
High Street, around a two minute walk from the hostel, at around 7.00pm
on the evening before he died. The resident recalled that the man was on
his way to a local pub but that he did not look the same as normal. He
asked the man how he was feeling, to which the man replied, “I’m alright,
just feeling a bit rough, I’ll soldier on”. The man joked that the evening
meal they had eaten at the hostel might have been the cause, saying, “I
don’t think the curry did me any good”.
50. The hostel records for 11 September, the night before the man died, show
that he returned to the premises at around 4.45pm and did not leave again
that night. Staff were confident that he could not have left the building
without being signed in and out, as the entrance can only be opened by a
button pushed by a member of staff in the office. The records for the
previous evening, however, show that the man had been to the pub that
night. It is possible that the resident has confused which night he saw the
man on the High Street.
51. At no time after the evening of 10 September did the man indicate to any
member of staff at the approved premises that he might be ill. A relief
worker, commented that he had seen the man several times on 11
September and that he “seemed in a very good mood”. Moreover, if the
man had been feeling unwell then, unless it was an emergency, the onus
would have been on him to arrange a medical consultation.
Response when the man collapsed
52. The man was attended to by the deputy manager and a relief worker,
when he was taken ill on 12 September. When the alarm was raised they
checked on the man promptly and called an ambulance immediately.
Until the arrival of the paramedics they monitored the man’s condition and
tried to make him comfortable and to communicate with him.
53. Shortly before the ambulance crew arrived, the man’s condition
deteriorated. His breathing became more laboured and his pulse faint.
However, as he was still breathing and the deterioration was just as the
paramedics were arriving, the staff did not begin cardio-pulmonary
resuscitation (CPR).
54. Whilst the relief worker was recently trained in first aid, including CPR, the
deputy manager is not trained. Not all staff at the approved premises are
trained. Instead, there are nominated first aiders whose assistance can
be called upon when necessary.
55. Probation Circular 35/2006 provides guidance on preventing deaths of
approved premises residents. It gives the following instruction:
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“Probation areas should refer to the Health and Safety Risk
Assessment ‘Approved Premises Management Guidance’ which has
been circulated to Areas and is available on EPIC [the Probation
Service intranet]. This states that ‘all supervisory staff must be trained,
as a minimum, in basic first aid’.”
56. In the man’s case it was not necessary for staff to commence CPR as he
was still breathing when the paramedics arrived. However, there could be
other occasions in which the intervention of staff might be required. In
such circumstances, the skills of properly trained and qualified staff may
be the difference between life and death.
The Chief Officer should ensure that all staff are trained in basic first
aid, as required by Probation Circular 35/2006. Consideration should
be given to training all staff in CPR.
57. There are currently no defibrillators at the approved premises. Such
devices are now widely installed in public places like shopping centres
and railway stations. They can give automated instructions to the
resuscitator on how to treat a patient, with little prior training required.
Following the death of a hostel resident in May 2008, I recommended that
the National Offender Management Service should review the costs and
benefits of providing defibrillators in all approved premises. This
recommendation was accepted in October 2008 and I do not repeat it
here.
Support to staff following the man’s death
58. Following the man’s death, the relief worker was offered the opportunity to
go home for the remainder of the day by the deputy manager, which he
accepted. The relief worker told my investigator that he was very happy
with the support that he received.
59. The deputy manager, on the other hand, felt that he did not receive
suitable support from his superiors. Whilst he was happy to receive
informal support from his colleagues at the approved premises, the deputy
manager felt that the contact he had with the assistant chief officer was
concerned more with events over the weekend following the man’s death.
He also felt that the contact he had with the director of operations might
have been better if it had been earlier and over the telephone rather than
on email.
60. The officer, who contacted the emergency services when the man
collapsed, was sadly told of a family bereavement on the same morning
that the man died. Whilst he said that he had little to do with looking after
the man when he collapsed, the approved premises officer felt that as he
was associated with two deaths on the same day it would have been nice
for someone to have contacted him to see how he was.
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61. Probation Circular 35/2006 says that, “following a sudden death Probation
Areas should consider providing support to residents and staff”. I consider
it essential that staff are provided with proper support following a death in
a hostel. Not least, this is part of the employer’s duty of care to its staff.
Unfortunately, the hostel manager was on leave at the time of the man’s
death. Had she not been, she might have been able to bridge the divide
between staff at the approved premises and area management.
The Chief Officer should review arrangements for supporting staff
following the death of an Approved Premises resident.
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RECOMMENDATIONS
1. The Chief Officer should ensure that all staff are trained in basic first aid,
as required by Probation Circular 35/2006. Consideration should be given
to training all staff in CPR.
Accepted – additionally, the four the approved premises staff who were
not first aid trained had been identified before The man’s death, and
arrangements had been made for them to attend the same four day
course as their colleagues. This training will take place in the early New
Year.
2. The Chief Officer should review arrangements for supporting staff
following the death of an Approved Premises resident.
Accepted – the South Wales Probation Trust will re-visit its arrangements
for providing support to staff in circumstances such as this and guidance
will be revised, promptly, if required.
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